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CCA (AHIMA) practice questions

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Question 1Health Record Content and Documentation

Who owns the physical health record created during a patient's hospitalization?

  1. The hospital that created it Correct answer.
  2. The patient named in the record
  3. The payer that reimburses the stay
  4. The admitting physician

Explanation

The healthcare organization that creates and maintains the record owns the physical medium and acts as custodian of the information. The patient has a right of access to the information but does not own the paper or electronic file.

Question 2Health Record Content and Documentation

Which purpose is served by the health record's clinical documentation?

  1. Determining nursing staff vacation schedules
  2. Supporting continuity of care among providers Correct answer.
  3. Establishing the patient's credit history
  4. Measuring the hospital's marketing reach

Explanation

The record communicates the patient's condition, treatment, and plan across providers and encounters, which supports continuity and quality of care. Billing, legal, and research uses are secondary purposes of the same documentation.

Question 3Health Record Content and Documentation

Under Medicare Conditions of Participation, a hospital must complete and document a history and physical examination within what timeframe after admission?

  1. 12 hours
  2. 8 hours
  3. 24 hours Correct answer.
  4. 48 hours

Explanation

CMS requires the history and physical to be completed and documented no more than 30 days before or 24 hours after admission, and before surgery or a procedure requiring anesthesia. The 24-hour window is the operative post-admission limit.

Question 4Health Record Content and Documentation

An operative report should be dictated or written immediately after surgery and completed within how long?

  1. 6 hours
  2. 48 hours
  3. 12 hours
  4. 24 hours Correct answer.

Explanation

Accreditation standards require the operative report to be completed immediately after surgery and finished within 24 hours. A brief operative note may be placed in the record before the patient leaves the operating or recovery area.

Question 5Health Record Content and Documentation

Which element belongs in a discharge summary?

  1. The hospital's staffing ratios for the stay
  2. The payer's internal claims edits
  3. The names of other patients on the unit
  4. The reason for admission and hospital course Correct answer.

Explanation

A discharge summary documents the reason for admission, significant findings, procedures performed, discharge diagnoses, the patient's condition, and follow-up instructions. It is a clinical summary, not an administrative or staffing document.

Question 6Health Record Content and Documentation

A paper record entry made by a medical student is unsigned. What must occur for the entry to be valid?

  1. The entry must be removed at discharge
  2. The health information department must initial it
  3. The entry must be rewritten by a nurse
  4. A supervising physician must countersign it Correct answer.

Explanation

Entries written by students or residents must be authenticated by the responsible physician through countersignature. Authentication confirms that the attending accepts the content as part of the record.

Question 7Health Record Content and Documentation

A physician realizes a progress note for Tuesday was never documented and adds it on Thursday. How should this late entry be handled?

  1. Enter it with the current date, time, and a late-entry note Correct answer.
  2. Write it on a blank page and discard the original page from the record
  3. Ask the nurse to write the note and sign the physician's name
  4. Backdate the entry to Tuesday and sign it as if on time

Explanation

A late entry must show the actual date and time it is written and clearly indicate that it refers to an earlier event. This preserves the integrity and chronological audit trail of the record.

Question 8Health Record Content and Documentation

A nurse writes the wrong dose in a paper record. What is the correct way to fix the error?

  1. Draw a single line through it, initial, date, and add the correction Correct answer.
  2. Cover the entry with correction fluid and write the corrected dose over it
  3. Recopy the entire page with the correction and discard the original page
  4. Erase the entry completely and rewrite the correct dose in the same space

Explanation

Corrections must preserve the original entry so the record remains a complete audit trail. A single line, the corrector's initials and date, and the corrected information achieve this without obliterating the original text.

Question 9Health Record Content and Documentation

A physician gives a telephone order to a nurse. What should the nurse do to complete the documentation?

  1. Read back the order and document it for physician countersignature Correct answer.
  2. Wait until the physician arrives to write the order in the record
  3. Document the order only in the nursing notes and never obtain a signature
  4. Ask another nurse to sign the order on the physician's behalf

Explanation

Telephone orders must be read back for verification, documented promptly, and countersigned by the ordering physician within the timeframe set by policy and state law. Both verification and authentication protect patient safety.

Question 10Health Record Content and Documentation

Which element is essential for informed consent to be valid?

  1. A notarized signature from the patient's attorney
  2. Disclosure of risks, benefits, and alternatives Correct answer.
  3. A witness who is a hospital employee and signs the form
  4. Approval by the utilization review committee

Explanation

Valid informed consent requires the provider to disclose the nature of the procedure, its risks, benefits, and alternatives, and to obtain voluntary agreement from a competent patient. Witnesses and notaries do not substitute for this disclosure.

Question 11Health Record Content and Documentation

Which document allows a patient to name someone to make healthcare decisions if the patient becomes unable to do so?

  1. A do-not-resuscitate order signed by the physician
  2. A durable power of attorney for healthcare Correct answer.
  3. An organ donation card signed by the patient
  4. A living will that states treatment preferences

Explanation

A durable power of attorney for healthcare designates a surrogate decision maker who acts when the patient loses capacity. A living will states preferences but does not appoint an agent.

Question 12Health Record Content and Documentation

Under HIPAA, which of the following is included in the designated record set?

  1. Psychotherapy notes held by the provider
  2. Medical and billing records used to make care decisions Correct answer.
  3. Peer review files and quality improvement studies
  4. Only those records the patient has already reviewed and requested

Explanation

The designated record set includes medical and billing records and other records a provider uses to make decisions about the individual. Psychotherapy notes and certain peer review or quality files are expressly excluded.

Question 13Health Record Content and Documentation

Which factor most directly determines how long a hospital retains its health records?

  1. The number of physicians who admitted the patient
  2. State law and the hospital's own retention policy Correct answer.
  3. The amount of storage space available in the file room
  4. The type of insurance plan that paid for the stay

Explanation

Retention periods are set by state statutes, regulation, and the organization's approved retention schedule, which may also reflect accreditation and payer requirements. Operational factors do not determine the legal retention period.

Question 14Health Record Content and Documentation

In a SOAP note, what does the 'O' represent?

  1. Orders that were placed during the visit
  2. Outcome goals the patient agreed to
  3. Onset of the patient's presenting symptoms
  4. Objective findings from the exam Correct answer.

Explanation

SOAP stands for Subjective, Objective, Assessment, and Plan. The objective component contains observable data such as physical examination findings and test results.

Question 15Health Record Content and Documentation

What is the main purpose of a problem list in the health record?

  1. To list the nursing staff assigned to each shift
  2. To document the administration time of every medication
  3. To record the patient's outstanding financial obligations and payments
  4. To summarize the patient's active and resolved conditions Correct answer.

Explanation

The problem list is a concise index of the patient's active and resolved conditions that guides care planning and continuity. It is a clinical summary tool rather than a financial or staffing record.

Question 16Health Record Content and Documentation

When should medication reconciliation be performed?

  1. At admission, care transitions, and discharge Correct answer.
  2. Only when the patient or family specifically requests it
  3. Only at the final discharge encounter
  4. Whenever a new medication is ordered

Explanation

Medication reconciliation compares the patient's current medications with newly ordered medications at admission, during transitions of care, and at discharge. This prevents omissions, duplications, and dosing errors.

Question 17Health Record Content and Documentation

A coder finds that the record documents 'pneumonia' without specifying the organism. What is the best action?

  1. Select a code based on the patient's symptoms
  2. Ask the patient what diagnosis was intended
  3. Query the provider for clarification first Correct answer.
  4. Assign the pneumonia code without further action

Explanation

When documentation is incomplete or ambiguous, the coder should send a compliant query to the provider before assigning a code. The provider is the only source who can clarify the diagnosis.

Question 18Health Record Content and Documentation

A progress note contains an identical paragraph from the previous day, including the same outdated lab values. What is the primary documentation concern?

  1. The note may be too long for the paper record
  2. Cloned text can misstate the current condition Correct answer.
  3. The note lacks a required nursing countersignature
  4. The note should have been entered in the EHR

Explanation

Copy-paste or cloned documentation can carry forward outdated findings and create inconsistencies that misrepresent the patient's current status. Each note should reflect the current encounter.

Question 19Health Record Content and Documentation

What makes an electronic signature valid in the health record?

  1. It is unique to the signer and authenticated Correct answer.
  2. It is witnessed by another clinician
  3. It is typed in a different font from the note
  4. It is added by the health information department

Explanation

An electronic signature must uniquely identify the person signing and be applied only by that person after authentication. It carries the same accountability as a handwritten signature.

Question 20Health Record Content and Documentation

Which documentation best supports the medical necessity of an inpatient admission?

  1. The authorization number issued by the patient's insurer
  2. A statement that the patient prefers to be admitted
  3. A list of all the patient's previous hospital admissions
  4. Physician notes describing severity and failed outpatient care Correct answer.

Explanation

Medical necessity is supported by clinical documentation of severity, intensity, and the reason a lower level of care is inappropriate or has failed. Authorization numbers and patient preference are not clinical evidence.

Question 21Health Record Content and Documentation

Which element belongs in the history of present illness?

  1. The patient's childhood immunization records and dates
  2. Location, duration, and severity of the pain Correct answer.
  3. The family history of heart disease and diabetes
  4. The patient's occupation and current tobacco use

Explanation

The history of present illness describes the current complaint using elements such as location, quality, severity, duration, timing, context, and modifying factors. Past, family, and social history are separate components.

Question 22Health Record Content and Documentation

What does the review of systems document?

  1. The patient's symptoms by body system Correct answer.
  2. The physician's physical examination findings
  3. The plan for diagnostic testing
  4. The patient's family members' illnesses

Explanation

The review of systems is a system-by-system account of symptoms reported by the patient. It is subjective history and is distinct from the physical examination and the plan.

Question 23Health Record Content and Documentation

Who is responsible for completing the medical portion of a death certificate?

  1. The physician who attended the death Correct answer.
  2. The funeral director
  3. The state registrar
  4. The hospital's health information manager

Explanation

The attending physician, or the medical examiner or coroner in reportable cases, completes the cause-of-death section. Other parties handle the demographic, disposition, and registration portions.

Question 24Health Record Content and Documentation

Under HIPAA, a patient generally has which right regarding the medical record?

  1. To approve every entry before it is filed
  2. To remove original documents from the record
  3. To rewrite clinician notes that they disagree with
  4. To obtain a copy and request amendments Correct answer.

Explanation

HIPAA gives patients the right to inspect and obtain a copy of their records and to request amendments to information they believe is inaccurate. They do not have the right to alter or remove original entries.

Question 25Health Record Content and Documentation

A clinician says a service was provided but no entry exists in the record. In an audit, how is the service generally treated?

  1. As documented because the clinician is credible
  2. As undocumented and therefore not billable Correct answer.
  3. As billable if a colleague confirms it
  4. As billable if the clinician remembers it

Explanation

The guiding principle is that a service not documented is considered not to have been performed for billing and audit purposes. Retrospective recollection does not substitute for contemporaneous documentation.

Question 26Health Record Content and Documentation

Which of the following is the primary purpose of the health record?

  1. Billing and reimbursement
  2. Legal defense
  3. Support of patient care Correct answer.
  4. Quality reporting

Explanation

The record exists first to communicate clinical information among caregivers so that care is coordinated, continuous, and safe. Billing, quality reporting, and legal defense are secondary uses that depend on accurate primary clinical content.

Question 27Health Record Content and Documentation

To support correct patient identification, what should appear on every page of a paper health record?

  1. Name and medical record number Correct answer.
  2. Date of the patient's most recent admission
  3. Room and bed number
  4. Insurance policy number

Explanation

Each page must carry patient identifiers that are unique and stable so a loose page can always be matched to the right patient. Name plus medical record number provides that link, while location, admission date, and payer can change or be shared by other patients.

Question 28Health Record Content and Documentation

What is the primary purpose of the medication administration record (MAR)?

  1. Summarizing the patient's allergy history
  2. Documenting each dose given and by whom Correct answer.
  3. Listing the patient's home medications on admission
  4. Recording the pharmacy's dispensing inventory

Explanation

The MAR is the contemporaneous record of what was actually given, when, in what dose, and by which caregiver. Home medication lists, dispensing records, and allergy summaries are separate parts of the record.

Question 29Health Record Content and Documentation

Who may make entries in a patient's health record?

  1. Authorized caregivers with privileges Correct answer.
  2. Any hospital employee who has computer access
  3. The payer's assigned case manager
  4. The patient's family members on request

Explanation

Documentation rights follow credentials, scope of practice, and granted privileges, and each entry must be authenticated by its author. General system access or a nonclinical relationship to the patient does not authorize documentation.

Question 30Health Record Content and Documentation

An inpatient is admitted at 8:00 p.m. and no history and physical has been recorded. Under Medicare Conditions of Participation, when must it be completed?

  1. Within 24 hours after admission Correct answer.
  2. Before the first medication is given
  3. Before the patient is discharged
  4. Within 48 hours after admission

Explanation

Medicare requires a complete history and physical in the record within 24 hours after inpatient admission when it was not performed within the 30 days before admission. Neither first-dose timing nor discharge timing satisfies the requirement.

Question 31Health Record Content and Documentation

Under typical accreditation standards, when must a complete operative report be placed in the record?

  1. Before the patient leaves the recovery room
  2. Within 72 hours of the procedure
  3. Before the patient is discharged home
  4. Within 24 hours after surgery Correct answer.

Explanation

The operative report is dictated or written immediately after the procedure and completed and authenticated within 24 hours. If the full report is not yet available, a brief operative note is entered before the patient leaves the recovery area.

Question 32Health Record Content and Documentation

Which abbreviation appears on The Joint Commission's "do not use" list?

  1. PO
  2. mL
  3. U Correct answer.
  4. mg

Explanation

"U" is prohibited because it can be misread as a zero, a four, or "cc"; the accepted form is "unit." The other abbreviations shown are on the approved list and are not prohibited.

Question 33Health Record Content and Documentation

After authenticating an electronic progress note, a clinician discovers that it contains an error. What is the correct action?

  1. Edit the original entry silently
  2. Enter a dated addendum Correct answer.
  3. Delete the original and re-enter the note
  4. Ask HIM staff to purge the original entry

Explanation

An authenticated entry remains part of the record, and corrections are made by adding a separate, dated and signed addendum that identifies the error and the correct information. Removing or silently altering an authenticated entry destroys the integrity and completeness of the record.

Question 34Health Record Content and Documentation

A patient decides to leave the hospital against medical advice. Which documentation is most important?

  1. A copy of the signed admission consent
  2. The payer's authorization on file
  3. Risks explained and patient's stated reason Correct answer.
  4. The names and relationships of visitors present

Explanation

The record should show that the risks of leaving were explained, that the patient nonetheless chose to leave, the patient's own reason, and that the physician was notified. Visitor identities and payer details do not capture the clinical and legal substance of the event.

Question 35Health Record Content and Documentation

Which set of elements belongs in a discharge summary?

  1. Vital signs recorded on the day of admission
  2. Every laboratory result obtained during the entire stay
  3. The patient's complete nursing care plan
  4. Principal diagnosis, course, and follow-up plan Correct answer.

Explanation

A discharge summary communicates why the patient was admitted, what happened during the stay, the discharge diagnoses and medications, the patient's condition, and the follow-up plan. It summarizes rather than reproduces the entire record.

Question 36Health Record Content and Documentation

What is the purpose of the audit trail in an electronic health record?

  1. It stores the patient's billing history
  2. It tracks who accessed or changed entries Correct answer.
  3. It replaces the need for user passwords
  4. It compresses records for long-term storage

Explanation

An audit trail is a chronological log of access and modification that supports security, data integrity, and accountability. It is not a billing file, an authentication substitute, or a storage tool.

Question 37Health Record Content and Documentation

A patient reports smoking one pack per day for 20 years. In which component of the history is this recorded?

  1. Review of systems
  2. Past medical history
  3. Chief complaint
  4. Social history Correct answer.

Explanation

Tobacco, alcohol, and other health habits are recorded in the social history portion of the history. The review of systems records symptoms by body system, and the chief complaint states the presenting problem.

Question 38Health Record Content and Documentation

Under charting by exception, a nurse documents which of the following?

  1. A single summary at the end of each shift
  2. Only findings that deviate from norms Correct answer.
  3. Every assessment finding in narrative form
  4. Only the care that was omitted

Explanation

Charting by exception depends on predefined standards and normal ranges, so staff record only variances and significant findings rather than restating normal assessments. It requires well-defined standards and careful implementation to remain a defensible record.

Question 39Health Record Content and Documentation

Which statement about ownership of the health record is correct?

  1. The provider owns the medium, not the information Correct answer.
  2. Ownership transfers to the patient at discharge
  3. The patient owns the physical file and everything in it
  4. The insurer owns the record because it pays for care

Explanation

The institution owns the physical or electronic medium and must protect and retain it, while the patient retains rights in the information it contains. That distinction explains why a patient may obtain copies and request amendments but cannot demand the original file.

Question 40Health Record Content and Documentation

Which statement best describes a hospital's legal health record?

  1. The organization's designated official business record Correct answer.
  2. Only records that attorneys or courts have requested
  3. The records the patient designates at each admission
  4. Every data element stored anywhere in the electronic system

Explanation

The legal health record is the subset of data the organization defines in policy as its official record of care, and it is what is disclosed in response to a request. It is not every element in the system, and neither the patient nor a requester decides its contents.

Question 41Clinical Coding

Which ICD-10-CM coding convention distinguishes right, left, and bilateral involvement when the condition permits?

  1. Sequela
  2. Excludes1 note
  3. Combination coding
  4. Laterality Correct answer.

Explanation

Laterality is an ICD-10-CM convention that allows codes to identify the right side, left side, or bilateral involvement. It is used only when the code set provides laterality characters for that condition. Sequela, combination codes, and Excludes1 notes address different coding rules.

Question 42Clinical Coding

A patient is seen for an established office visit for a new rash. During the same visit, the physician performs a separately identifiable incision and drainage of an abscess. Which modifier is appended to the E/M service?

  1. 59
  2. 57
  3. 24
  4. 25 Correct answer.

Explanation

Modifier 25 reports a significant, separately identifiable E/M service performed by the same physician on the same day as a procedure. The E/M service must be above and beyond the usual preoperative and postoperative work of the procedure. Modifier 24 applies during a postoperative period, 57 is for decision for surgery, and 59 is for distinct procedures.

Question 43Clinical Coding

For an inpatient hospital stay, the principal diagnosis is best defined as the condition established after study to be chiefly responsible for which of the following?

  1. Occasioning the admission Correct answer.
  2. Generating the highest DRG payment
  3. Requiring the most expensive treatment
  4. Being present on admission

Explanation

The UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission. Cost, DRG payment, and mere presence on admission do not determine principal diagnosis. A chronic condition present on admission is not principal unless it occasioned the admission.

Question 44Clinical Coding

A surgeon removes an entire appendix during an inpatient procedure. Which ICD-10-PCS root operation is assigned?

  1. Excision
  2. Removal
  3. Resection Correct answer.
  4. Extraction

Explanation

Resection is the root operation for cutting out or off all of a body part without replacement. Excision is partial removal, removal is without cutting, and extraction is pulling or pulling out. Complete removal of the appendix is therefore resection.

Question 45Clinical Coding

HCPCS Level II codes are used primarily to report which of the following?

  1. Physician office visits
  2. Supplies, drugs, and services not represented by CPT Correct answer.
  3. Inpatient procedures only
  4. Diagnoses and symptoms

Explanation

HCPCS Level II is a national code set for supplies, drugs, durable medical equipment, and services not represented by CPT. Diagnoses are reported with ICD-10-CM, and physician office visits are generally reported with CPT E/M codes. Inpatient procedures are reported with ICD-10-PCS.

Question 46Clinical Coding

A patient with no current illness comes to the office for a routine gynecologic examination with no abnormal findings. Which ICD-10-CM code is reported?

  1. Z01.419 Correct answer.
  2. Z00.00
  3. Z12.4
  4. N95.1

Explanation

Z01.419 is the code for an encounter for gynecologic examination without abnormal findings. Z00.00 is a general adult medical examination, and N95.1 is menopausal symptoms. Screening for cervical neoplasm would be reported with a screening code only when that is the purpose.

Question 47Clinical Coding

A patient is seen for a fractured wrist after falling from a ladder while cleaning gutters at home. Which code identifies the external cause?

  1. The fracture code only
  2. W11.xxxA, fall from ladder, initial encounter Correct answer.
  3. Z91.81, history of falling
  4. An activity code only

Explanation

External cause codes identify the cause of an injury and are reported after the injury code. W11.xxxA describes a fall from a ladder at the initial encounter. The fracture code alone does not identify the external cause, and an activity or history code does not replace the cause code.

Question 48Clinical Coding

A patient is examined in the office by a physician in the same group practice who has never personally seen the patient, but another physician in the group has seen the patient within the last 3 years. How is the visit reported?

  1. Preventive visit
  2. New patient visit
  3. Established patient visit Correct answer.
  4. Consultation

Explanation

An established patient is one who has received professional services from the physician or another physician of the same specialty in the same group practice within the previous 3 years. Personal unfamiliarity with the patient does not make the patient new. A consultation requires a request and report to another provider.

Question 49Clinical Coding

A patient with type 2 diabetes mellitus and stage 4 chronic kidney disease is admitted. The physician documents that the chronic kidney disease is due to diabetes. How should this be coded?

  1. E11.22 and N18.4 Correct answer.
  2. E11.29 and N18.4
  3. E11.9 and N18.4
  4. E11.21 and N18.4

Explanation

E11.22 is the combination code for type 2 diabetes mellitus with diabetic chronic kidney disease. The stage of chronic kidney disease is reported separately with N18.4 for stage 4. E11.9 is used without complications, and E11.21 is for diabetic nephropathy, not CKD.

Question 50Clinical Coding

A patient has hypertension and heart failure. The physician documents that the heart failure is due to hypertension. Which code assignment is correct?

  1. I11.9 only
  2. I50.9 only
  3. I11.0 and I50.9 Correct answer.
  4. I10 and I50.9

Explanation

I11.0 reports hypertensive heart disease with heart failure, and an additional code from I50.- identifies the type of heart failure. I10 would be reported only if the heart failure were unrelated to hypertension. I11.9 is used when heart disease without heart failure is documented.